It’s always the vaccines: Harold Ramis and autoimmune vasculitis

Last week, one of my favorite comedians and filmmakers of all time passed away unexpectedly. I’m referring, of course, to Harold Ramis, whose work ranged from movies like National Lampoon’s Animal House (the first R-rated movie I ever saw, actually), to gems like Ghostbusters and and Groundhog Day. In fact, in retrospect, when I posted about Brian Hooker and the antivaccine movement trying to resurrect the hoary corpse of the conspiracy theory that the CDC is some how “covering up” data that would prove that the antivaccine cranks were right all along about mercury in vaccines as a cause of autism, I probably should have called it “Groundhog Day for Mercury.” The reason, of course, is that the movie Groundhog Day was about a TV meteorologist played by Bill Murray, who is forced to relive Groundhog Day over and over again, with no one aware of the time loop except for him. The difference between the antivaccine movement’s conspiracy theories about mercury and the movie, of course, is that in the movie Bill Murray’s character, having acquired wisdom and won over the girl, so to speak, finally breaks out of the time loop to wake up on the morning of February 3. Not so the antivaccine movement, which seems stuck in a perpetual time loop dating back to around 2004 or 2005.

I know the analogy isn’t perfect, but there’s another aspect of the antivaccine movement that I’ve pointed out many times that’s come up again in the wake of Harold Ramis’ death. No, antivaccinationists didn’t directly blame Harold Ramis’ death on vaccines (although I half-expected them to). They did, however, “wonder” about whether the condition that sickened him nearly four years ago, afflicted him the last few years of his life, and ultimately killed him, autoimmune vasculitis, is related to vaccines. Why? Because in the antivaccine movement, it’s always about the vaccines. Always. Even when it’s not about the vaccines, it’s about the vaccines, as demonstrated by this post on the antivaccine crank blog Age of Autism entitled Harold Ramis, Inflammatory Vasculitis and “Rare” Conditions by Wayne Rohde. Here’s a classic example of what we in the skeptic biz know as JAQing off:

So how did this horrible disease afflict Mr. Ramis? Dr. Waseem Mir, a rheumatologist at Lenox Hill Hospital in New York told CBS news that only 1% of the US population has this disease, making it extremely rare. However, Dr. Peter Merkel, a rheumatologist and director of Penn Vasculitis Center at the University of Penn medical school told CNN that “Mr. Ramis had one of 15 identified variants of vasculitis. None of these conditions individually affects more than 200,000 people in the US. But if you add them all up together, it’s not rare, and the chances are everybody knows somebody, directly or indirectly, that is affected.”

Now does that last sentence sound familiar? Maybe in discussions about vaccine injury? If two leading rheumatologists cannot agree whether or not this medical condition is rare, why not examine some previous medical cases of vasculitis?

In a paper presented by Tomljenovic and Shaw in 2012 regarding the death of two individuals who were administered the HPV vaccine, tissue samples of the brain led the authors to interpret the results as demonstrating an autoimmune cerebral vasculitis. Now, we can confidently assume that Mr. Ramis did not receive a Gardasil vaccine, but it does bring vaccinations into the question. Another study, published in 2009 by Birck, Kaelsch, et al, titled “ANCA-associated vasculitis following influenza vaccination: causal association or mere coincidence?” did not prove a causal association between influenza vaccine and vasculitis, but it did assert that in rare cases vaccination might induce vasculitic disease. Now we have the possibility that influenza vaccine might, under “rare” conditions, induce vasculitis.

Yep. To antivaccine activists, it’s the vaccines. It always was the vaccines. It will always be the vaccines. Unfortunately, searching for “Harold Ramis” and “vaccines” reveals that Mr. Rohde’s article has metastasized far and wide on the Internet and Facebook, as any good conspiracy theory would. As I said, there’s no real evidence. Indeed, Mr. Rohde cites a website, Vasculitis UK, as saying that “Flu and Pneumonia vaccines are not recommended for vasculitis patients.” That’s odd. I Googled until I found what must be the webpage on the Vasculitis UK website to which Rohde was referring, entitled, appropriately enough, Vaccinations. Guess what it says? (Here’s a hint: What it says reveals Mr. Kohle to be either profoundly ignorant or profoundly disingenuous—or both.) Surprise! Surprise! It says almost the exact opposite of what Mr. Rohde says it says. The reason for not recommending some vaccines has nothing to do with their causing or potentially exacerbating vasculitis and everything to do with a common trait among patients being treated for autoimmune vasculitis, namely immunosuppression:

Patients taking immune-suppressants should not receive live vaccines such as yellow fever, typhoid and measles.

Live vaccine contains a small amount of the infection itself. Under normal circumstances the patient can fight off this small amount of infection but this is not possible for the vasculitis patient. This will have implications for holidays in destinations and where live vaccines are recommended, eg Africa, Asia, and Latin America.

Flu and Pneumonia vaccines are recommended for vasculitis patients. These are not live vaccines. Where the patient is unsure about a particular vaccine it is important to speak to the doctor about this issue.

Note how it says “Flu and Pneumonia vaccines are recommended for vasculitis patients.” What are not recommended for vasculitis patients are live attenuated virus vaccines, such as the shingles vaccine, not because they cause or exacerbate vasculitis but because vasculitis patients are often immunocompromised as part of the treatment of their autoimmune condition! Live virus vaccines aren’t recommended for these patients for exactly the same reason they’re not recommended for cancer patients currently undergoing chemotherapy or other patients who require treatments that are immunosuppressive. Mr. Rohde’s article is extremely deceptive on this point, and just plain wrong. One wonders if he was intentionally so obtuse as not to recognize that the flu vaccines being warned against were only the live vaccines, such as Fluenz, which is used in the UK) and that the reason why live virus vaccines are not recommended for many vasculitis patients is because they are immunosuppressed, not because they have an autoimmune vasculitis!

Also in his risibly bad argument, Mr. Rohde cites two of our favorite newer antivaccine “scientists,” Lucija Tomljenovic and Christopher Shaw in perhaps one of their most ridiculous papers ever:

In a paper presented by Tomljenovic and Shaw in 2012 regarding the death of two individuals who were administered the HPV vaccine, tissue samples of the brain led the authors to interpret the results as demonstrating an autoimmune cerebral vasculitis. Now, we can confidently assume that Mr. Ramis did not receive a Gardasil vaccine, but it does bring vaccinations into the question.

No. It. Does. Not.

I analyzed that paper when it came out. It showed nothing of the sort. Tomljenovic and Shaw claimed to show was that somehow the HPV vaccine caused some sort of autoimmune cerebral vasculitis in a young woman who died due to an HPV protein depositing in the cerebral vasculature and leading to an antibody-mediated response. The details are in my post, but the CliffNotes version is this. There were two young women who died whose brain tissue Tomljenovic and Shaw got a hold of because the parents thought that Gardasil had killed their daughters because they had died weeks after receiving a dose of the HPV vaccine. In both cases, the autopsy didn’t show any abnormalities in the brain that could account for either girl’s unexpected death. If these girls had had an immune-based vasculitis, whatever the cause, serious enough to kill them, it should have been visible as severe inflammation in the brain tissues on normal H&E sections (sections stained with the usual blue and pink dye and no special immunohistochemical stains). Then, the IHC might reveal the potential cause. In one of the two cases, Tomljenovic and Shaw bemoaned how the pathologist didn’t use any specific antibodies for inflammatory markers but rather noted changes consistent with terminal ischemic-hypoxic encephalopathy. What that means is that the pathologist thought that the changes he observed were consistent with the brain’s having suffered a significant period of time with low blood flow right before death, a very common finding that a competent pathologist who does autopsies regularly should be able to identify on standard H&E microscopic sections.

So in the paper being cited by Mr. Rohde, what we have are non-pathologists, who clearly don’t know how to interpret common neuropathological findings, throwing every inflammation-related antibody in the book at the brain sections from these unfortunate deceased young women, and then concluding that there was some sort of neuroinflammation because they saw staining in the blood vessels in the brain. There’s one huge problem, though: Totally inadequate controls. Tomljenovic and Shaw’s findings could just as well have been due to nonspecific staining. Not only didn’t they examine sections of age-matched normal brains as controls (the very minimum they should have done), but they also neglected to do some very basic controls for any IHC experiment, as I described in detail when I blogged the study. In the other paper cited by Mr. Rohde, there is no good evidence that the flu vaccine causes autoimmune vasculitis. In fact, the authors conclude:

In the literature different subtypes of vasculitis have been repeatedly reported after influenza vaccination. Several trials in patients with preexisting auto-immune disease failed to indicate an increased risk for disease recurrence after influenza vaccination but these investigations might be underpowered to detect this very rare but relevant side effect. Although our report does not prove a causal association between vaccination and vasculitis, it seems possible that in rare cases vaccination might induce vasculitic disease.

“It seems possible”? “In rare cases”? This is thin gruel. Here’s what probably happened. The authors, however they noticed it, came across four cases of people with autoimmune vasculitis who were diagnosed after influenza vaccination. They did a literature search to see if there was any evidence that might suggest if the flu vaccine can induce such a vasculitis. They failed to find any. So they waffled at the end that “it seems possible” and excuse away the negative studies by calling them underpowered. Of course, even if it is “possible” that the flu vaccine can cause autoimmune vasculitis, the evidence presented suggests that such an event is very, very rare indeed. Basically, Mr. Wohle confused correlation with causation, as antivaccine activists are so wont to do.

Mr. Wohle finishes up by invoking—of course!—the Vaccine Court and cases compensated. It never ceases to amuse me how antivaccinationists hate the Vaccine Court when it doesn’t find what they want but have no problem dumpster diving into it to find cases they do want to use to demonize vaccines. Funny, though, how out of 15,000+ petitions, Mr. Wohle only found 20 related to vasculitis, and the four that he picked to list are thin gruel indeed.

It all just goes to show that, to antivaccine cranks, no matter what the disease is, it’s about the vaccines. It’s always—always—about the vaccines, and if there’s a dead celebrity whose disease can be abused to draw attention to your antivaccine views, so much the better.

46 Comments

I don’t know if you saw the Oscars last night, but Bill Murray mentioned Harold Ramis during his presentation of an award. Jim Carrey was also a presenter of an earlier Oscar. It’s a blessing Carrey didn’t come running onstage to enlighten us all as to the vaccine “connection” to Ramis’s condition.

As i know to my cost any rare ailment is a magnet for woo of all kinds. If its one where the cause is uncertain so much the better because the holy trinity of vaccines/nutrition/lifestyle will be invoked. All Hail the Yogic Multivitamin of Natural Immunisation!

Damn, I didn’t know. Egon Spengler was my favorite of the four ghostbusters.
Mostly because little Frenchie me could only remember one of all of these foreign names, and it was this one. Also, he was the most competent of the 3 scientists in this little jig of theirs.

Now, we can confidently assume that Mr. Ramis did not receive a Gardasil vaccine

Are they sure? After all, men can get the HPV, too, and there has been talk of extending the recommendation of the HPV vaccine from girls to boys. Maybe Harold Ramis volunteered.

And, well, if there is still mercury in vaccines, whatever vaccines manufacturers and actual chemical analysis would say, maybe there is some stealthy Gardasil in all vaccines. We put so much useless stuff in there already, adjuvants, preservatives, virus DNA, bits from human and chicken embryos…

What? Eh, if you want to go conspirationist, at least do it properly. Don’t stop half-way. Amateurs.

They did, however, “wonder” about whether the condition that sickened him nearly four years ago, afflicted him the last few years of his life, and ultimately killed him, autoimmune vasculitis, is related to vaccines. Why?

1% of a population is hardly extremely rare. On a typical working day I probably come in direct or indirect contact with over one hundred persons, so it’s not like the two rheumatologists are actually disagreeing.

Also, while stretching the latter rheumatologist’s quote a bit, if you assume that all of those 15 variants each have close to the mentioned 200,000 affected US citizens, when added together one gets 3 million affected. This would be pretty close to 3,14 million or so if you take the 1% claim seriously. .. (and apologies for subverting anti-vaccer logic because too tired to go search for actual numbers).

“….On Monday, Ramis was surrounded by family in his North Shore home when he died at 12:53 a.m. of complications from autoimmune inflammatory vasculitis, a rare disease that involves swelling of the blood vessels, said his wife, Erica Mann Ramis. He was 69.

Ramis’ serious health struggles began in May 2010 with an infection that led to complications related to the autoimmune disease, his wife said. Ramis had to relearn to walk and suffered a relapse of the vasculitis in late 2011, said Laurel Ward, vice president of development at Ramis’ Ocean Pictures production company. He never fully recovered….”

Why did Rohde go to the U.K. Vasculitis website and lie about what he read on that website?

Rohde lives in the United States and he could have gotten information about vaccines from the Vasculitis Foundation’s website:

1% of a population is hardly extremely rare. On a typical working day I probably come in direct or indirect contact with over one hundred persons, so it’s not like the two rheumatologists are actually disagreeing.

I noticed that “extremely rare” was an indirect quote. I didn’t follow the link, so I don’t know if that was taken out of context.

You might ask: If a condition affects 1% of people, then how large a group do you need to have at least a 50% chance (assuming everything is suitably random) of including someone with the condition? If I’ve done the calculation right, the answer is 69. Most people have acquaintance circles several times larger than that, as you point out.

Technical Reports
Review of a published report of cerebral vasculitis after vaccination with the Human Papillomavirus (HPV) Vaccine

“….The working group also reviewed information from the Vaccine Adverse Event Reporting System (VAERS) database, available medical records, and the medical literature. A single VAERS death report of cerebral vasculitis was found in a 37-year-old female with immunodeficiency and multiple medical problems who had received HPV4 vaccine 45 days earlier.

Assessment: After thorough review and discussion of the Tomljenovic article, the CDC-CISA working group identified substantial methodological concerns and lack of evidence to support the authors’ conclusions that the two patients had vasculitis, that HPV4 vaccine particles were in the brain tissue, or that HPV vaccine was causally associated with death from cerebral vasculitis.”

Apparently, friends or (possibly) the family doctor are more likely to persuade the parent to vaccinate than PSAs.

It’s sort of consistent with the general rule in marketing and customer service that people are more likely to tell others about a bad experience than a good one. And, that it takes 10 good experiences to counteract the effect of one bad experience. And, that’s IF you are lucky enough to get them to come back for a chance to get a good experience.

It’s the same sort of error that Mitt Romney made in his now-infamous remarks about the 47%. It’s true that about 47% of Americans pay no net federal income tax, and it was also true at the time that 47% of poll respondents favored Obama. Romney’s mistake was to assume that the two groups were the same group, because they happened to be the same size and it fit his preconceived notions.

In the other paper cited by Mr. Rohde, there is no good evidence that the flu vaccine causes autoimmune vasculitis.

I went looking for the paper in question (“ANCA-Associated Vasculitis Following Influenza Vaccination: Causal Association or Mere Coincidence?”) but turns out that I don’t have access to the J. Clinical Rheumatology. Looking at the Table of Contents, they seem to specialise in publishing case studies.

That particular issue of the journal turns out to have a guest editorial by Zafrir, Agmon-Levin & Shoenfeld making antivax hay out of the case study:

I was diagnosed with a form of vasculitis (Wegener’s disease) two years ago. Since then I’ve met only one person who knows another person with the disease. Plus, my doctor says I’m one of only two of her patients that have been diagnosed with this condition. Some statistics I’ve come across during my research indicate that the number of people in the U.S. diagnosed with Wegener’s is 12-13,000, and the # of persons diagnosed in the U.S. with this disease every year is 2 per million, though this is rising because of more knowledge about the condition. So at least one of the fifteen or so types of vasculitis is rare – OK? And I’m betting my life it WAS NOT caused by a vaccine!

“In conclusion, our case series cannot differentiate between spontaneous or vaccination-triggered vasculitis disease activity. Due to the very rare incidence of autoimmunity after vaccination, large randomized-controlled trials would be necessary to clarify the relationship. From a population-based view, the preventive effects of influenza vaccination in high-risk patient on morbidity and mortality most probably outweigh these rare albeit sometimes severe individual side effects.”

“Mere Coincidence?” Interesting construction for a sholarly study. If you two can’t get it, I probably can’t either, but I’ll give it a shot tonight.

But that’s not important now. What caught my eye was Tomljenovic. I know, I know — every Tom, Dick and Harry Tomljenovic is named Tomljenovic. But it still seemed more than Mere Coincidence that Tomljenovic was the name of an anti-vaccine ophthalmologist from UBC cited in the Journal of Facebook. That Tomljenovic believes the JCVI (UK analogue of the CDC) “withheld” information on vaccine dangers from the public; also, that multiple studies have replicated Wakefield.

Cripes — is there no limit to the number of times a meme can be recycled?

But I get the vaccine not just to protect myself, but also to protect others like infants too young to be vaccinated and my mother who is old enough her immune system might not respond enough to the vaccine to protect her.

Since Tomljenovic and Shaw are not pathologists, why didn’t they take a little walk down the hall to the UBC Pathology Department and get some help setting up the investigation and interpreting the histology and immunostains? I know these people (they trained me) and they’re very approachable. That’s what a researcher usually does when he or she ventures outside their area of expertise.

Personally, if I were peer reviewing a paper like this, the first question I would have is if the investigators had a neuropathologist on board to interpret their histology and immunohistochemistry, and if they don’t I’d reject the paper right away. You can’t do neuropathology without a neuropathologist, at least not on human specimens. (Some investigators who do mouse work don’t need a pathologist to interpret their slides, although I have to be convinced.)

Toccoah, 4 years ago I was diagnosed (not biopsy-confirmed) by a GP with Henoch-Schonlein purpura. He said I’d be better within 6 weeks, which I was not, so I went to a rheumatologist. She said it could be HSP, but she wanted to do chest and sinus CTs to rule out Wegener’s, “because HSP is so rare in adults.” I found this somewhat confusing, because Wegener’s is also pretty rare. I guess there just weren’t any horses in this scenario, and we were trying to figure out which zebra it was. BTW the CTs were clear, and I had a kidney biopsy that confirmed HSP.

Anyway, although I’m confused by the 1% = extremely rare statement, it does make sense that although some types of autoimmune vasculitis are indeed extremely rare, when you add up all the cases of all the types, autoimmune vasculitis is not rare.

Personally, if I were peer reviewing a paper like this, the first question I would have is if the investigators had a neuropathologist on board to interpret their histology and immunohistochemistry, and if they don’t I’d reject the paper right away.

Interestingly, I tested positive for SLE (lupus) only after I was given a pneumonia vaccine by an allergist and became very ill. Now, I have an immune complement disorder, and my resistance to many pathogens is extremely low- including the strep that causes pneumonia. My father died from a myocardial staph infection and CHF after a battle with pneumonia- at the age of 36. It’s not something I will form an immunity to because of the innate flaws in my immune cascade, but the allergist foisted this shot on me after seeing my percentages, despite my protests. I think he did it to make some bank. Pneumovax is not a live vac, but my body responded as if it were. I became insane ill, exactly as if I had pneumonia, and it dragged on for weeks. I was sure I’d been given a live vaccine. After a month I improved, but other factors of my health declined rapidly. Four months later I was diagnosed with the autoimmune disease (which I’d tested negative for previously). Now, I don’t think that the vaccine ’caused’ the lupus specifically- as in I don’t think if you shoot twenty other people (normal healthy people or even those with the same condition) that they will get the same disease. However, I think it may have triggered an autoimmune reaction that became the chronic condition. Something dead was put into my bloodstream, and my body was ill-equipped to handle it. So an excess of antibodies with nothing specific to fight would not know what to attack if the vaccine contents were flushed out after a few days, yet the flag would be raised (so to speak). The marker was then present for a pathogen that could not be found… A 404 error, basically. That seemed to send me spinning into self destruct. So I think if someone has a physiological condition that a doctor may not be aware of (if the patient isn’t) or educated on (if it’s not their specialty) then vaccines could certainly trigger an autoimmune reaction. Frankly, I haven’t found many physicians to be high in common sense. Therefore I believe it may be the luck of the draw, and I caution you against claiming that all anti-vaccination ideas are nonsense. Vaccines are not made to ‘help you’. They’re a product, made by a for-profit company, and a doctor is just a salesperson at the end of the day. If they were all truly beneficial, there would be stronger evidence that they work well in vitro on wider populations, and the data doesn’t support that. Flu vacs have never been found more than 50% percent effective. Also, if every single ingredient in a vaccine isn’t listed, why should I trust anyone enough to take it? Safe to say, I won’t be getting another, now have lupus, and may well still die of pneumonia. Food for thought.

I caution you against claiming that all anti-vaccination ideas are nonsense.

Nobody here denies that vaccines have no negative events. Heck, that’s why countries have compensation programmes for vaccine injuries. Yet a great many antivaxxers accuse vaccines of causing negative events that are beyond the realm of possibility.

Vaccines are not made to ‘help you.

Wrong. They are made to train your immune system to fight off infections that can have highly negative effects on your health and wellbeing, including killing you.

They’re a product, made by a for-profit company…

Food is grown by farmers, for profit, processed into foodstuffs by companies like Nestle, for profit, and sold in supermarkets, for profit. We still need to eat. The fact that vaccines are made for profit does not make them bad. In addition, it would be far more profitable for both the Pharma companies and the medical practitioners to not vaccinate and treat the diseases.

If they were all truly beneficial, there would be stronger evidence that they work well in vitro on wider populations, and the data doesn’t support that.

Firstly, vaccines are not administered in vitro, so your argument is illogical, to put it politely. Secondly, women who get vaccinated while pregnant tend to have better outcomes.

Flu vacs have never been found more than 50% percent effective.

Another false claim. I would ask for a citation, but I suspect you’d come back with something from Mercola, Null or another quack.

Also, if every single ingredient in a vaccine isn’t listed, why should I trust anyone enough to take it?

Every single vaccine ingredient is listed.
I’m sorry your doctor was such a damned fool about giving you a vaccine over your well-warranted concerns. I suggest you file a vaccine injury report and also report your allergist.

Something dead was put into my bloodstream, and my body was ill-equipped to handle it. So an excess of antibodies with nothing specific to fight would not know what to attack if the vaccine contents were flushed out after a few days, yet the flag would be raised (so to speak). The marker was then present for a pathogen that could not be found… A 404 error, basically.

What cells normally express something on the surface that looks like pneumococcal capsular polysaccharide?

It is the case that a couple dozen cases of SLE following Hep B vaccination have gained some attention (with only temporality gluing them together so far, as I can tell), but this is the first I’ve heard of a pneumococcal version.

To get to SLE, you have to at least get to antinuclear antibodies, which means you have to expose cell innards such that B cells can be sensitized to them, right? This is what I was wondering about.

“Four months later I was diagnosed with the autoimmune disease (which I’d tested negative for previously).”

Is lupus something routinely tested for? If not, the fact that Raeven had been tested for it suggests that s/he already had symptoms suggesting the disease, and the negative results could have been a false negative.

“Is lupus something routinely tested for? If not, the fact that Raeven had been tested for it suggests that s/he already had symptoms suggesting the disease, and the negative results could have been a false negative.”

Assuming of course that Raeven isn’t a driveby antivaxer riffing on Orac’s invoking of Dr. Gregory House’s famous statement “It’s never lupus”.

Is lupus something routinely tested for? If not, the fact that Raeven had been tested for it suggests that s/he already had symptoms suggesting the disease, and the negative results could have been a false negative.

No, taken at face value, it suggests that Raeven already had something suggesting that SLE was a possibility and it was checked out. I don’t know what sort of testing allergists do that might get one from point A to point B with an adult patient.

I’m just one rheumatology patient — noteworthy ANA, anti-Ro, anti-LA* — by virtue of sudden-onset Raynaud’s. The first thing done was, in fact, “it’s not lupus.” After that, it’s just watchful waiting. No routine titers, because nothing seems to be going on.

ANA testing seems to suffer more from false positives than false negatives (randomly, here and references therein), so I’m taking it at face value.

I don’t see any medical contraindications for receiving an adult pneumonia vaccine for persons who have SLE and/or complement disorders

Right, but the argument as constructed is that (1) the vaccine caused the SLE, (2) the complement disorder meant that this intervention offered little benefit in the first place, and (3) the end result is something that wouldn’t be epidemiologically picked up as far as such guidance is concerned.

Narad — you have Reynaud’s and it got you into a rheumatology clinic? Interesting. I’m intrigued because I have what is certainly undiagnosed Reynaud’s, and have never really taken it particularly seriously. A whole finger or toe (not always the same one; it can be any of my ten fingers or ten toes, or more than one, often on the same extremity not always) will go totally white and numb when cold. This long hard winter has, of course, made that extra fun. 😉 Although, I did finally find a pair of socks which mostly works to keep my toes warm. It runs in my mother’s side of the family; she has it, and her father had it. At one point is it worrisome? Is this something I should’ve at some point mentioned to a doctor?

At one point is it worrisome? Is this something I should’ve at some point mentioned to a doctor?

Beats me. Mine came on really suddenly, so my PCP did some blood work. I was off to rheumatology when ANA titer came back along with both of the Sjögren’s autoantibodies. Their observation was “somtimes people just get Raynaud’s.”

It’s pretty easy to control with medication if it’s bothersome. I’d probably have to switch up from diltiazem to sildenfil if it got worse, though, which I understand is unlikely to be covered by insurance.